Saturday, November 24, 2007

Dr. Drug Rep

To see how I made an extra $30,000 in 2002, click here. The article is published in this Sunday's New York Times Magazine. By the way, the Wyeth-sponsored "Faculty Development Programs" are still being held; a friend tells me he just went to one in Florida.

36 comments:

"Dr. Drug Rep" is a great article that helps to shed much light on Big Pharma's influence over medical practices in America.

I have been researching conflicts of interest in medicine over a particular environmental exposure, mold within water damaged buildings.

I contributed to the following linked article that is in this month's edition of the International Journal of Occupational and Environmental Health. The article is titled, "American College of Occupational and Environmental Medicine, A Professional Organization in Service to Industry." My contribution begins on pdf page 17. http://www.ijoeh.com/pfds/IJOEH_1304_LaDou02.pdf

My point in telling of the above article is that I can research and write all I want. But for one, such as yourself who has actually experienced the influence of the sirens of industry, to write of the matter carries much weight. Your words, as a former insider, will help thousands to better understand the perverse influence industry is having over science and medicine in the US today.

Dr. Carlat - I commend you for coming forth on your stint as Dr. Drug Rep however, you failed to touch upon the very lethal nature of Effexor and how it has one of the most difficult withdrawals of all SSRIs. Please note my research to be found at:http://SSRI-Research.com. Additionally, I have archived almost 9000 articles, documents, medical abstracts and legal testimony on the dangers off SSRIs, to be found at:http://groups.yahoo.com/group/ssri-research.

What is most criminal is that these drugs with BLACK BOX WARNINGS or DEATH AS A KNOWN SIDE EFFECT are being dispensed to children like candy.

There is much more for you to expose than a little hypertension caused by these drugs. Please do your own research and speak up and out. The public needs your honesty.

I'm a psychiatrist in private practice in NYC, and I don't see drug reps anymore-not since I left my inpatient position a year-and-a-half ago.

But I always figured, if you're gonna prescribe meds, they have to come from somewhere. And the pharmaceutical companies are entitled to market and make a buck just like everyone else. So if you see drug reps from all the different companies, the influence has to even out.

But in reading your article, I was convinced I'm probably wrong, and that a much more insidious effect creeps in over time. I certainly preferred some drug reps to others.

I was particularly struck, okay, terrified, by your description of the way the AMA sells information, and that that, and purchasing prescribing information from pharmacies aren't illegal. Everyone's so conscious of HIPAA laws, you'd think there would be some corresponding protection for physician privacy.

Does the AMA have access to information about all physicians, or just AMA members?

The AMA Masterfile includes data from all physicians in the U.S., whether AMA members or not. Here is a URL to learn more about how the AMA attains this data: https://profiles.ama-assn.org/amaprofiles/info/pdf/primarysource.pdf

The leasing of the Masterfile is nothing more than an income stream for the AMA, and there is little to say in its defense.

Thanks for presenting to me an informative and better understanding of the inside workings especially as it pertains to the practice of Psychiatry.

As a very long time support person and care giver to my spouse I can even remember way back when there were no Psychopharmacologists and the Psychiatrists still used a couch. I guess we call this progress.

Knowing intimately of my spouse’s challenges over 4 decades, the inability of your profession and its science to give the patient any definitive answers other than its many theories I personally am an advocate for all treatment options knowing the difficulty to control and stabilize many of these severe mood disorders into long-term remission.

While I am not against the use of drugs and/or any therapy option deemed reasonably safe and efficacious, I am for the patient being educated to make informed decisions in collaboration with a trusted, compassionate, knowledgeable and licensed health care professional.

"Maybe. I’m sure I persuaded many physicians to prescribe Effexor, potentially contributing to blood-pressure problems and withdrawal symptoms. On the other hand, it’s possible that some of those patients might have gained more relief from their depression and anxiety than they would have if they had been started on an S.S.R.I. Not likely, but possible." --- Dr. Daniel Carlat

I would also like to see the medical profession and especially the APA better regulate itself in what I also see are many improprieties not only in the pharmaceutical marketing to the professionals but also to the public and to clean up its act in the field of research with its ghost writers and so called prestigious doctors lending their names to studies.

It also happens that Effexor XR was one medication at doses as high as 900 mg per day which accorded my spouse a long-term remission of approximately one year which was unheard of in her case history before the refractory problem surfaced once again. I might also add that being knowledgeable of her blood pressure increase we were able to easily overcome that side-effect with an additional medication. I shall also point out, in my wife’s case history, upon several occasions she was able to withdraw from the Effexor XR as well as other psychotropic medications without any withdrawal symptoms which most importantly brings up the importance of proper clinical monitoring of one’s patient regardless of study data.

My spouse has since gone on as a study subject to have obtained pretty remarkable results and almost continuous long-term remission from a non-pharmaceutical treatment option.

Dr. Carlat,My first feelings when I read your article was, "oh c'mon, they are the smartest guys in school and they suddenly can't figure out they are being used for money?" Then I realized my past struggle with integrity and money. I began to see you were someone like I was, with a lot of attention given to you because of what you did on the outside (as opposed for just being valued for who you are on the inside.) Our culture is so outer focused and it is easy to get pulled into more money more stuff more prestige, etc.

Will we ever learn that we are just ok being who we are I wonder.

I knew the scrip info was for sale but didn't know how it was done. Also fascinating that the AMA is in on it. Great info there.

Thank you for putting this out there. I read that 50% of all people are now on some sort of prescription medication. Score one for the BIG PHARMA. The NY Times and its readers have a love affair with medicine in general(like follow blindly.) I think you were good to de-mystify this.

Thanks for your NYT article.It deserves to be widely read.I find a number of themes I have blogged about for the past 2 1/2 years played out in your article including; how meta-analysis can be and are misused,how drug companies can stack the deck and cook the books in their sponsored clinical trials, how the tenets of EBM can be perverted.I admire the courage you have to do what you did and to write about it.

Thanks for an interesting article. I'm a rheumatologist and have sometimes given "drug rep talks", and I've struggled with some of the same issues you raise in your article (of note: the going rate they offer me is now an unbelievable $2000 per talk).

One aspect to giving talks that you don't mention is whether your own prescribing patterns changed as a result of giving so many talks. I've often wondered if a certain company asked me to give talks becasue I prescribed so much of their drug (IE as a reward to a loyal customer), of if it was because I didn't but they thought they could change my ways by employing me.

One other point: while the AMA does make a lot of money by selling information about physicians from their masterfile, they also offer an easy way for physicians to "opt out" and not allow anyone to have access to their prescribing information. In fairness to the AMA this point should have been made in your article.

Dr. R., Yes, you are quite right about the opt-out option. It is not easy to find from the AMA website, but the direct URL is: http://www.ama-assn.org/ama/pub/category/12054.html.

The opt-out must be renewed every 3 years, and it does not prevent drug companies from obtaining your information for uses other than giving it to drug reps in the field. In other words, opting out still allows them to analyze your prescription info for marketing purposes.

I would propose an "opt-in" rather than an opt-out process, and I would urge the AMA to not release any info at all when a physician has opted out.

Thanks very much for baring your soul so openly. I am a psychiatrist and was approached by a drug rep to talk about Lexapro. I declined, but have always wondered if my suspicions were correct. After reading your experience I see they were.

I also want to make a point here, that it is not just doctors being influenced by "lunch and learns". Nurses, and staff [using a psych hospital as one example I witnessed]are often invited to the Lunch and Learn. This is where the added danger to the patient is expanded, when a nurse or psych staff attend this pharma rep "learning session" and think they've been taught something, when in fact it was medication pimping at it's finest.One can't possibly walk away from a lunch and learn promoting one psychiatric medication and take that seriously--but they do.

The scary part is, that trickle down effect. Pharma knows what it's doing, their advertising agencies are top notch.

Yes, it's conflicted and corrupt.What are consumers and complainers going to do about it?

It's not a mystery that families of patients who settled out of court cannot speak about their loved one's harm or death after being paid by Eli Lilly for example.

This is so obvious, I find it hard to believe consumers can be so un informed when taking psychotropics.

Read the Zyprexa documents hosted by Furious Seasons, and it should cause outrage enough. Then wonder why the state of Arkansas is going after Risperdal for the same reasons!

Thanks for your article which I read in the NY Times this morning. How lucky you are to have gotten out of that sticky, unethical situation.As I was reading your story I had hoped your were collecting the business cards of the doctors you spoke to. Or at least kept a record of where you spoke.Out of a sense of justice, a simple letter to each of these practitioners offering an apology or explanation in an attempt to correct a wrong, seems in hindsight (MY hindsight), a fine human act.This excellent article does a great deal in that direction also.But, perhaps you did write that letter...

While you were a Dr. Rep. your sales focus on your medical "audience" only gave you a partial picture of the effect of your actions and that of other MD's out their pitching at lunchtime, even at this moment.As a patient, I was once on the receiving end of this possibly criminal, certainly greedy and unethical practice. At one sharp point in my life a few years ago I was diagnosed with degenerative spine and bone disease, AS, various crippling types of arthritis, and Type 2 diabetes all within one month. Ugh! Within a year, I was no longer able to work (teach) and was easily granted full disability from the Social Security Administration.When referred to a prominent rheumatologist I thought I may have found an educated person who offered me some help, primarily relief from pain and a new ability to stand and walk. Ha!

He operated an interesting clinic and I now suspect he could have been one of the Dr. Reps you describe. He treated me right out of the current research. Quoted the research to me to prove I needed certain prescriptions.Because a percentage of women with my illnesses and abrupt life transitions are thought to be depressed, at first he proscribed Effexor for me.That was before a long weekend break which I took off to relax at a remote cottage I had on the Puget Sound. Second day of taking Effexor while writing I noticed initially that I was scrambling the words in a sentence. All the words were there just not in correct order. As I went on writing I became unable to write even 5 letter words with the letters in correct order. I became frustrated and frightened.This growing inability to literally "think straight" terrified me. I had been warned privately by a nurse in the clinic, not the physician, to be very careful if and when I stopped taking the drug. She took me aside and whispered to me to come off of it slowly if I quit taking it. She had once been given Effexor and had such incredible mental illness when withdrawing that she had to quit working for a while.So, I spent the rest of the weekend taking a half and then no Effexor.I reported this to the physician who was not at all impressed. He said that I must need Zoloft instead.It took about two weeks on Zoloft for me to become a kind of sweating zombie. I could not think clearly and any effort at all produced extraordinary perspiration. When I reported this to the physician he merely wrote the symptoms in my medical record.

Fortunately, my friends noticed the change in me and the dead white pallor. They convinced me to stop taking the drugs and assured me that anyone who had all such loss at one time would be naturally grieving and not depressed. Or certainly not clinically depressed. Where do they teach commonsense in medical school?

My experience of misdiagnosed and wrongly treated illness came from a rheumatologist. Would I have fared any better had I been referred to a psychiatrist? Do they all hear the same Pharma-prepared pseudo-scientific song and dance?

I suggest that psychiatrists and other doctors who prescribe psycho-tropic drugs to their patients take a long weekend off and try them on themselves. Record their impressions verbally, in writing.Document the changes. They won't die from taking SSRIs, but they may get some insight into the effect of Effexor and the others on a healthy mind. After all, how positive are doctors when they even diagnose someone as "depressed"? After diabetes isn't this the next most popular, new catch-all illness for what may be perfectly normal reactions to living situations-- especially among the young?

Unfortunately, it must be gratifying to garner attention as a gadfly villifying the "Big Pharma" monsters, and positing physicians as greedy numbskulls, seduced by the Dark Side. An article such as yours,really speaks only to the writer's lack of ethics, or ability to be "bought" by salespeople.

As a speaker for Wyeth, I am not "for sale" and I do not EVER say anything I don't believe. I actually educate, and attack the stigma toward psychiatric illness that health professionals all have. Many with whom I present to, really are not very skilled nor understanding of the data. When I was asked by other companies to say things that were not true, or present information that was not data I said, very simply, no.

The fact is "Big Pharma" is the ONLY pharma, like it or not. To pretend otherwise, or to exhort that the advances made in pharmaceutical development were possible some other way, is just bullshit. Large pharmaceutical companies are not holy, selfless, organizations, but that does not mean they cannot be useful to our patients.

Pandering to the anti-psychiatric, anti-medicine fringe, especially to spice up ones click-thoughs, or subscription numbers for other projects, is just as sleazy as what one purports to expose.

I very much appreciated your article in the NY Times on your experience as a so-called educator of doctors. I am a psychologist in the private practice of psychotherapy who sometimes refers patients to reputable psychiatrists for evaluations for meds, but has been very aware of the over-selling of the effectiveness and the under-notification of the side-effects of many of the commonly prescribed psychotropic medications. One issue you didn't address in your article is that the huge amounts of money the drug companies spend on the marketing of drugs is part of the reason for the tremendous rise of health costs in our country. I don't know if you're one of the dwindling numbers of psychiatrists who actually do psychotherapy, but the use of these drugs with concurrent psychotherapy has been shown, in many studies, to be better than drugs alone. Anyway, thanks for your excellent and revealing article. I have forwarded it to all the professional organizations of which I am a member. Stephan Tobin, Ph.D.

Dr. Carlat,I found your article to be a concise piece on what I have often thought. It takes a lot to constantly be aware, as a consumer, of what one's doctor is prescribing and why. While I understand why one might want a doctor to lend an air of legitimacy to those pitches, the drug companies should just put them on their payroll; then there won't be any confusion as to what the doctor's role is.I work in the wine industry and sometimes I think there are more restrictions on what I do than in the drug trade.In our industry what you did would be called a "consulting"; brought in to lend an air of gravitas to our product. But make no mistake, all of our customers would know, that the consultant is being paid to help pitch the product.When a friend became a doctor and I saw the access the drug reps had in trying to establish early on a certain loyalty, that's when I started asking my doctors why they were prescribing a certain drug. Even now, I come home, research whatever drugs have been prescribed to me, call back and ask, why one over another. I am my only advocate.

As a young physician in residency, I applaud any effort to turn medicine away from its seedy business side and let doctors get back to the practice of doing what is right for the patient. A doctor who is pressured by money or any other motive to prescribe a drug or paint data in a certain light for Big Drug is not getting the point of what it means to be a doctor and what is special about it -- i.e. it's one of the few professions where impartiality separates the good from the bad.

I believe clinically practicing physicians should not be hawking drugs and paid by Drug Cos to do it.....or at least not paid so handsomely. I can see a $50 meal for a drug you believe in, I can't see why you need $750 for it. Your article was brave and needed. We are advocates for our patients, NO ONE ELSE. The "doctor" who commented otherwise in this thread does not understand what the Hippocratic Oath is about truly.

That being said, a factor could be the prolonged doctor-creation process in this country. First, it takes very long and a huge debt trail to become a physician (for most). It is not uncommon for my co-residents to have $200,000 of debt AFTER GRADUATING RESIDENCY! When you look at dentists making $195,000 on average after four years of school. Or, even P.A. APNs or CRNA's making $120,000 if they work 60 hours/wk, can you get as mad for a doctor who is looking at $140,000 (what you make and what I am looking at unless I specialize after internal medicine residency) for taking some drug rep money here and there? Yes, you still can, but it's harder. We need to do something about the overly long and grueling way we create doctors in this country and perhaps we can get to the point where MDs are satisfied at $150,000/year.

Still, the above is a side point. I've heard it said that starving artists never complain that they never dine at the fanciest restaurants and that true doctors should be the same. The degree of detail and the AMA complicity in helping drug corps maximize every dollar they can from a drug -- whether or not indications dictate that such a drug be so profitable is a crime any Dr. Drug rep aids.

This is a great article. I've already sent around to a lot of my friends and colleagues, including my roommate who is a drug rep for Bayer. Though not in medicine myself, I've seen the sales side vicariously through her eyes, and always felt it very unsavory, and your portrayal certainly amplifies that. I don't want her to feel bad about her job, but at the very least I think there are lessons in tact for drug reps to learn from your account.

Tangentially, I take Effexor XR, and (thankfully) am very happy with the drug. Despite not knowing whether my doctor was an attendee of one of these lunches (come to think of it, the drug companies should be obligated to provide the names of doctors who attend these lunches), I'm glad he's prescribed it for me.

I'm kidding. A little. Maybe not that much. Back in '02 I went to see a family-practice doc about depression, and I'd hardly gotten the word out of my mouth before he was pressing Effexor into my hand. What a vile, vile drug. I took the lowest dose, gained weight uncontrollably, and felt like I spent my days smiling tolerantly at something that would never arrive. After three months I'd had enough, and tapered off. The withdrawal was astonishing. I was sick as a dog physically and emotionally. Spent a week sobbing hysterically in some crazy belief that I'd caused my 24-year-old cat's death the year before. It was absolutely nuts.

Never, ever again. I'd responded quite nicely to a tricyclic some years before, by the way. There hadn't been any medical need to boost Effexor sales with me.

Oh, son of a bitch! I just finished reading the piece. You _knew_ about the withdrawal symptoms, and you kept on pimping the stuff! I don't understand why your patients keep going to you. A lapse in judgment like that, I have a hard time believing that's a one-time thing. That's not an honest mistake; that's a decision informed by character.

I don't understand this "mea culpa, I was like an addict, hooked on the dough" baloney, either. I'm a single mother, and I support my kid by writing freelance ed stuff. I need the money. I still turn down work that involves intellectual dishonesty or the presumption that kids can't read and imagine. This isn't hard. The sense of dismay and/or revulsion is a pretty good tipoff that a job's no good. Then I say politely, "No, I'm sorry, I can't write that." There are other jobs in the world.

I would like to know what kind of restitution you're doing. Please don't say "writing these articles". That's not restitution; that's cashing in on the confessional-memoir/medical-memoir confluence that's hot at the moment.

If you haven't made commensurate restitution, I would suggest that you figure up the amount you received from Wyeth, divide it by your hourly rate, and donate that number of hours to uninsured patients.

my reaction to the piece is that it isn't completely plausible that he could have been as naive as he claims. what did he do at mass general, wash bed linens?

it's natural to want to make yourself the hero of your own story, especially if it's a confessional. i give him points for being open. furthermore, he paints an accurate picture of relationships that many lay-persons may not be aware of.

also, psychiatrists shoot themselves in the foot with this class of drugs by neglecting to emphasize the withdrawal effects. perhaps they should try taking them first. watching from the outside doesn't give a complete understanding of the pain involved.

patients, on the other hand, really need to take more responsibility for their pharmacological treatments. many are frightened and overly predisposed toward attributing every ache pain they have to a new medicine. and most of all, be realistic. if you are going to take one of these drugs, it is going to come along with its own set of problems. it is a trade-off and the patient must be involved in assessing whether it's worth it. doctoring requires some art and intuition, there is never complete information available. the doctor can only assist in selecting potentially appropriate agents and evaluating the effects, many of which he must rely on the patient to report.

i do like the idea of restitution by volunteering hours to the uninsured. that is a clever and balanced approach.

Give me a break, Carlat. Now the world is expected to believe that doctors learn and teach and practice whatever pharma says? Hmm, Dr. Carlat is certainly enjoying a fair amount of media attention as a “whistle-blower”. Seems to live for attention. Glad to see that others are onto him, too.

Physician, heal thyself: The issue is not that pharma companies pay doctors to speak on behalf of their drugs, but that SOME doctors have appallingly WEAK ETHICS. On interviews about this blog, this psychiatrist readily projects his own deficit upon the rest of his profession. DON'T paint us all with the same offensive and dirty brush. Not only is it a psychological mistake, it's a logical fallacy: Association does not prove causation. Just because a minority of doctors' moral compasses point whichever way money flows, the majority doesn't follow. One bad apple does NOT spoil the barrel--throw out the bad apple.

I am a physician fed up with being told how to do everything by everyone who thinks they know better or that they know I can’t possibly be trusted do anything right: How to practice medicine (& how much my work is worth) by Medicare, HMOs, and many non-physicians, and how to make good moral decisions by the Pope and the AMA (and after this, probably Congress--oh, the irony!). That's what always happens after this sort of "expose". No rational thought, just knee-jerk throw-the-baby-out-with-the-bathwater--Oh-dang-we-didn't-think-about-the-baby-dying-if-we-did-that.

Mandating (as some suggest) the publication of physicians' names who "take" pharma money doesn't prove they are “biased”. Most researchers and doctors are ethical & serve the greater good.

Continuing Medical Education lectures are often catered by pharma. So what? CME lectures must be unbiased, speakers must disclose all financial ties to their topic, and topics must stick to FDA-APPROVED drug use labelling (this is the only "message" FDA permits drug reps to sell, so of course, it’s “on message”) or the speaker must state that a use is “off-label”. If the lecture doesn’t meet these ethical criteria, it can’t be used for CME credit.

Many pharma reps are nice people, who believe they are helping others. It is clear to most physicians when they’re being “sold”, and most are willing to sit through a nice rep’s “message” to glean the useful information or the free samples for patients who can’t even afford generics (an increasing number). It takes a lot more than a sandwich to influence my care of patients (or being paid an honestly-earned speaking fee--set by me, not the rep--for preparing an unbiased lecture instead of earning more money in the office). When a rep has said I had to use only company slides and talk nice about his drug, you know what I said? Nope. Homey don't play dat. My slides, my talk, my fee, it's CME, or no deal. Goodbye. And if I don’t use a drug, I don’t see the rep.

Most physicians prescribe on the basis of clinical guidelines and solid science. Regardless of who funded it, science has to meet rigorous and public peer review to be considered valid. And there isn’t enough money coming from outside of pharma to research the drugs we need or even fund some medical school training. Congress won’t pay for it. There is more to sensationalist “whistle-blower” stories like this than ever gets to the public. My fellow American, do your own research and think with your own head. Skepticism goes both ways.

Dear Dr. Carlat,Keep the money and keep writing. I took 3 months to get off of Effexor XR at 225mg daily and I had all the horrible side effects. With the short half life of Effexor, a day where you forgot your pill in the AM and left for the day was a nightmare. I don't know if my DR. listened to a rep. like you or was selling it like you. I went off Effexor because I was inspired by another Times writer, Kira Salak, "The Vision Seekers" 9/12/2004 to travel to Peru to see a shaman and drink ayahuasca to cure my depression. That worked. I haven't heard of anyone promoting that alternative. My psychiatrist didn't want to hear about it when I came back. My trial and success seems as valid as the random choices in the approved medication matrix of today. We and our parents put so much thought, effort and investment into choosing our educational sources to achieve professionalism. it's a pity when as professionals we compromise our parents efforts promoting misinformation in so many business fields.

Dr. Carlat,I had to write to thank you for your recent article in the New York Times. It is rare today to see such integrity and a willingness to go public about pharmaceutical marketing. I own and operate www.paxilprogress.org, which is a peer support web site for antidepressant withdrawal. It is the misinformation that doctors have received on this category of drugs that created the huge need for those suffering in withdrawal to seek out their peers for firsthand, unbiased information. This is what paxilprogress is all about. Thousands of ssri users supporting each other through withdrawal. Most have given up on their prescribing psychiatrist, since denial of withdrawal is rampant. So they go it alone, with the help of those who have been there before them.

My son is a survivor (just barely) of Paxil withdrawal. My husband is hopelessly addicted to Effexor. Even the smallest weaning amount causes a suicidal reaction.(never suicidal prior to Effexor...mild depression) You can imagine my horror when I discovered the truth behind these drugs. As a nurse of 24 years I trusted my fellow medical professionals. That trust almost cost my son his life. Some, even with full disclosure may choose to take an ssri, and that is their choice. But they have the right to know the good, the bad and the potentially ugly before making that decision.

I speak out at every opportunity I get so that others will have full disclosure of potential side effects and adverse reactions . This is a basic right of all patients. Hopefully your article is the beginning of a change in how drugs are marketed. I wish there were more doctors who were willing to look beyond the lunch and see the facts.

Very Interesting Article! I greatly enjoyed your frank self-examination. I am an academic Ob/Gyn sunspecialist and have been asked to do lunch talks as you describe. The company that asked me insisted that I use their slides, something that made me feel ethical discomfort because of the difference between my expressing my opinion and my expressing the company opinion.

I have found, however, that some companies, including Wyeth, will pay an unrestricted grant for a physician to give grand rounds at a teaching hospital, often on a subject only tangentially related to their product (or sometimes not at all related). The grant to the medical school usually includes travel expenses and a modest honorarium for the speaker. They have absolutely no say in the content of the talk. I have found this arrangement acceptable in the past. I am wondering if you or others finds this objectionable and the reasons why.

Doctor -- any chance you'll be directing any of those cruelly-gotten gains to an awareness campaign so that (apparently naively) trusting patients are made aware of the drug's utterly devastating withdrawal effects before they're put upon this path?

I have a million "if only-s" after my absolutely grueling struggle to kick Effexor, but the largest one of all is, if only I'd had all the facts. I would never in a million years have started taking this drug had I known. All I can do now is share my cautionary tale.

I find it VERY interesting that a Psychiatrist is commenting on hormone Replacement Therapy issues???

Secondly, it is very appauling for a physician to bash drug companies when he "spoke" for them for years, but once removed from their speaker's list (for questionable reasons), he now bashes other physicians for educating others as speakers??? Wow, how hypocritical!

Dr. Carlat, I find it hard to believe that your experience with the pharmaceutical industry resulted in the kind of epiphany that you have described. Do you really mean to say that prior to your "awakening" circa 2002, you had no suspicions, objections, dissatisfactions, or reservations about eating all those lunches/dinners in medical school, residency, and beyond? About actually spending a substantial amount of time with reps? About taking all that cash for doing something that you knew was clearly marketing and not educational? About watching one industry devour another? About engaging in "professional" endeavors that your father likely would never endorse? I just don't believe that you were so oblivious to what you were doing. I think it is a clever historical revision to frame it as such, simply because most of your readers probably wouldn't understand your deeper devotion to psychiatry; and despite most of your ranting, it's likely that your readers cannot understand the depth of your disgust with psychiatry. In my own experience, the discomfort of even casual conversation with most reps felt slimy from my first encounters with them in medical school, and the sliminess only intensified throughout my psychiatry training. I'm guessing that you had a similar experience and that you were keenly aware of all that was going on around you.....and that your luncheon speaking was the ultimate effort to immerse yourself into the pharma culture....which is what you needed, in the end, to be able to launch your current projects (which I'm sure your father is proud of).

Despite completing my psychiatry training relatively recently (in Boston), I only inadvertently discovered you and your blog and report within the last 6 months (and in somewhat of a strange way, as I was googling "psychology physical examination," a topic that I find way more fascinating and enveloping that your idealization of psychology prescribers). Since reading your blog and book (purchased with much hesitancy, although I was grateful for your essential message in the end), I've gone through several stages of emotional evolution regarding one issue in particular: prescribing. At first, like most psychiatrists, I was enraged by your casual endorsement of psychology prescribing, and you are well aware how much it makes psychiatrists' "blood boil." Without going into much more depth, the way I see your two-front approach to "reforming" psychiatry is that it is actually a perfect recipe for stirring up the profession (of mental health, that is): behead pharma, and empower psychology. These are the most potent aspects of your movement. But your plan for solving the mental-health crisis through psychology prescribing is bad. Perhaps if I have the stamina at some point, I'll outline a better way to do this without 1) creating pseudo-prescribers out of psychologists and further complicate the arena of psychopharmacology, and 2) destroying the MD psychiatrists and the PhD psychologist in favor of an army of hybrid mental health professionals that a) can't talk to physicians and b) aren't respected by psychologists anymore than psychiatrists currently are(n't).

I only wish you would unveil yourself so that we could carry on a productive debate. You are obviously articulate and intelligent. There are many places where we could carry on a debate, such as Psych Times, Clinical Psych News etc...

Earn CME Credits Online with The Carlat Psychiatry Report

Dr. Carlat's Book

Click the book cover to go to the Unhinged website

About Dr. Carlat

I am a psychiatrist in Newburyport, Massachusetts and an Associate Clinical Professor of Psychiatry at Tufts Medical School (but note that the opinions expressed in this blog are not those of Tufts). I graduated from the psychiatric residency at Massachusetts General Hospital in 1995, and am the founder and publisher of three CME newsletters, including The Carlat Psychiatry Report. In March 2012, I left the publishing world to work on conflict of interest issues for The Pew Charitable Trusts, as director of the Pew Prescription Project. I returned to Newburyport and Carlat Publishing in September 2014.